dr. I Made Artawan, M.Biomed., Sp.

An
FK UNDANA 2017
 Fluid and electrolyte physiology
 Water comprises 60% of the body weight of an
average adult, although the percentage is lower
in obesity, since adipose tissue contains less
water than lean tissue.

 The total body water is divided functionally into

 Intracellular fluid spaces (ICF = 40% of body weight)
 Extracellular fluid (ECF = 20% of body weight)
 Interstitial (14% of body weight)
 Intravascular (6 % of body weight)
Fluid and electrolyte physiology

 Total body water (TBW) – percentage of body

composition consisting of water, approximately
60% of body weight, less in obesity and more in
infants.

 Intracellular fluid (ICF) volume – that part of the

TBW contained within the cells, approximately
40% of body weight and 2/3rds of TBW. Muscle
cells contain 75% water and fat cells have <5%
water
Fluid and electrolyte physiology

 Extracellular fluid (ECF) volume – that portion

of the TBW outside the cells, approximately 20%
of body weight and 1/3rd of TBW, sustained
osmotically mainly by sodium

 Interstitial fluid volume – that portion of the

ECF outside the circulation and surrounding the
cells.
 Fluid and electrolyte physiology
 Intravascular fluid volume
 The total blood volume consisting of red and white cells
and plasma. Approximately 5-7% of the body weight.

 The plasma volume is that part of the ECF contained

within the circulation and supported oncotically by the
plasma proteins, separated from the interstitial fluid by
the capillary membrane. Comprises approximately 3-4%
of the body weight.

 The effective circulatory volume refers to that part of the

ECF that is in the arterial system (normally 700 ml in a 70
kg man – 10% of body weight) and is effectively
perfusing the tissues.
PowerPoint 2007
This presentation demonstrates the
new capabilities of PowerPoint
Text, Graphics & Pictures
through examples. You can view it in
Slide Show or by browsing through
the slides in Normal View. These SmartArt
slides are designed to give you great
ideas for the presentations you’ll
create in PowerPoint 2007! Themes & Quick Styles

New Layouts
 Fluid and electrolyte physiology

 Intracellular and extracellular spaces separated

by the cell membrane with its active sodium
pump, which ensures that sodium remains
largely in the ECF.

 The cell contains large anions such as protein

and glycogen, which cannot escape and,
therefore, draw in K+ ions to maintain electrical
neutrality (Gibbs-Donnan equilibrium)
BODY FLUID ELECTROLYTES
- NON IONS : DEXTROSE, UREUM, CREATININE
- IONS (SALTS) :
CATIONS : Na+, K+, Ca++, Mg++
ANIONS : HCO3-, Cl-, PHOSPHATE, PROTEIN,
ORGANIC ACID.

ELECTROLYTES AND PROTEIN OSMOTIC PRESSURE

DETERMINANT.

INTRACELLULAR EXTRACELLULAR
FLUID FLUID
MAIN KALIUM (K+) NATRIUM (Na+)
CATION
MAIN ANION PHOSPHATE (PO4-) CHLORIDE (Cl-)
 Osmolarity
 Osmolarity measure the concentration of a
solution, expressed as the number of particles of
solute per 1 L solution. Osmolarity is measured in
milliosmoles per liter of solution (mOsm/L).

 Osmolality
 Osmolality is another measure of the
concentration of a solution, expressed
as the number of particles per 1 kg water of
solution. Osmolality is measured in milliosmoles
per kilogram of water (mOsm/kg)
 Osmotic pressure (μ)
 Osmotic pressure (μ) is a property of
solutions with different osmolarities and
separated by a semi-permeable
membrane.
 It is the force exerted by the sum of
osmotically active particles (electrolytes)
that do not freely pass through
semipermeable biological membranes
(which allow the passage of water but
not of all solutes).
 Tonicity
 Tonicity is a comparative measure of the osmotic
pressure of two solutions separated by a semi-
permeable membrane.

 Under this condition, water shifts from the

solution with lower osmotic activity to the
solution with increased osmotic activity.

 The osmotic pressure gradient between the two

solutions is described as the tonicity

 The tonicity of the blood is 288 ± 5 mOsm/kg H2O

 Tonicity
 Plasma tonicity can be calculated by measuring
the plasma concentrations of Na, Cl, glucose, and
urea but the main determinant of plasma tonicity
is the Na concentration.
FUNCTION OF BODY FLUID

• METABOLISM REACTION

• NUTRIENT

• CIRCULATION INTEGRITY

• OSMOLALITY

• THERMOREGULATION
FUNCTION OF BODY ELECTROLYTE

 GENERAL :
- MAINTENANCE BODY FLIUD OSMOLALITY
- CHEMICAL REACTION  CELL MEMBRANE
EXCITABILITY , MUSCLE CONTRACTION, NEURON
IMPULS TRANSMISSION.

 SPECIFIC :
- Ca++  BLOOD COAGULATION
- H+  pH
- NaHCO3, NaH2PO4  BUFFER OF pH
 Physiology of fluid balance
 Just as the heart constantly beats, fluids and solutes
constantly move within the body  maintain
homeostasis
 Fluid Movement
 Within the cell
 Diffusion
 Osmosis
 Active transport
 Within the vascular system
 Capillary filtration  hidrostatic pressure
 Reasbsorbtion  plasma colloid osmotic pressure
 Physiology of fluid balance
Diffusion
 In diffusion, solutes move from areas of higher
concentration to areas of lower concentration
until the concentration is equal in both areas.
Osmosis
 In osmosis, fluid moves passively from areas with
more fluid (and fewer solutes) to areas with less
fluid (and more solutes).
Active transport
 In active transport, solutes move from an area of
lower concentration to an area of higher
concentration  requires energy (ATP)
DIFFUSION
OSMOSIS
 ACTIVE
TRANSPORT
Maintenance of fluid balance

 Many mechanisms in the body work

together to maintain fluid balance.
 Kidney
 Antidiuretic Hormone (ADH)
 Renin-angiotensin-aldosterone system
 Atrial natriuretic peptide (ANP)
 Thirst mechanism
 Maintenance of fluid balance
 Kidneys
 Nephrons form urine by filtering blood.
 If the body needs more fluid, nephron tubules
retain or reabsorb water and electrolytes.
 If the body needs less fluid, tubules absorb less,
causing more fluids and electrolytes to be
excreted.
 Kidneys also secrete renin, an enzyme that
activates the renin-angiotensin-aldosterone
system.
 Aldosterone secreted by the adrenal cortex
regulates sodium and water reabsorption by the
kidneys.
 Maintenance of fluid balance
 Hormones
 ADH— Also known as vasopressin, ADH is produced by
the hypothalamus to reduce diuresis and increase water
retention if serum osmolality increases or blood volume
decreases.

 Renin-angiotensin-aldosterone system — If blood flow

decreases, the juxtaglomerular cells in the kidneys
secrete renin, which leads to the production of
angiotensin II, a powerful vasoconstrictor; angiotensin II
stimulates the production of aldosterone; aldosterone
regulates the reabsorption of sodium and water in the
nephron.
 Maintenance of fluid balance
 Hormones
 ANP —This hormone, produced and stored in the
atria of the heart, stops the action of the
reninangiotensin-aldosterone system; ANP
decreases blood pressure by causing vasodilation
and reduces fluid volume by increasing excretion
of sodium and water.
 Maintenance of fluid balance
 Thirst Mechanism
 Regulated by the hypothalamus
 Stimulated by an increase in ECF and
drying of the mucous membranes
 Causes a person to drink fluids, which are
absorbed by the intestines, moved to the
bloodstream, and distributed between the
compartments
Assessment and monitoring of fluid balance
Assessment and monitoring of fluid balance
Assessment and monitoring of fluid balance
Assessment and monitoring of fluid balance
Assessment and monitoring of fluid balance
Assessment and monitoring of fluid balance

 Dehydration – the term ‘dehydration’ strictly

means lack of water, yet it is also used
colloquially to mean lack of salt and water or
even more loosely to describe intravascular
volume depletion.
 Dehydration derives from an imbalance between
water intake and losses. It consists of a reduction
of ISS and ICS water.
Assessment and monitoring of fluid balance

 Thus, with respect to water losses/sodium

losses we can distinguish among three types of
dehydration :
• hypotonic (water losses < sodium losses);
• hypertonic (water losses > sodium losses);
• isotonic (water losses = sodium losses).
Assessment and monitoring of fluid balance

 Intravascular volume depletion – this signifies a

deficit in plasma or total blood volume, as in burns
or haemorrhage, or a reduction in circulating
volume secondary to salt and water loss.
FLUID THERAPY
 Resuscitation - Administration of fluid and
electrolytes to restore intravascular
volume.

 Replacement - Provide maintenance

requirements and add like for like
replacement for on going fluid and
electrolyte losses (e.g. intestinal fistulae).

 Maintenance - Provide daily physiological

fluid and electrolyte requirements.
HOW TO DO FLUID THERAPY ??
FLUID THERAPY
 Appropriate fluid and electrolyte prescriptions
may be administered orally, enterally,
subcutaneously, or intravenously, depending on
the clinical situation

 Does the patient need this for :

a. resuscitation,
b. replacement of losses, or
c. merely for maintenance?

 What is the patient’s current fluid and electrolyte

status and what is the best estimate of any current
abnormality?
FLUID THERAPY
 Which is the simplest, safest, and most
effective route of administration?

 What is the most appropriate fluid to use

and how is that fluid distributed in the
body?
 FLUID THERAPY
 Resuscitation
 A resuscitation regimen is needed to restore
and maintain the circulation and the function of
vital organs .
 In the event of blood loss from injury or surgery,
plasma loss e.g. from burns or acute
pancreatitis, or gastrointestinal or renal losses
of salt and water .
 Fluid use : crystalloid, colloid, blood component
FLUID THERAPY
 Replacement
 Any fluid prescription should incorporate not
only daily maintenance requirements, but
replacement of any ongoing abnormal losses.
 In the case of a patient with losses from the
gastrointestinal tract, e.g. from a fistula or
from nasogastric aspiration, the fluid
prescription should include the daily
maintenance requirements
FLUID THERAPY
 Maintenance
 Maintenance prescriptions should aim to
restore insensible loss (500-1000 ml), provide
sufficient water and electrolytes to maintain
normal status of body fluid compartments
 Adult/children  Formula 4 : 2 : 1
 Ex : BW 60 kgs 
(4x10 kg) + (2x10 kg) + (1x40 kg) = 100
ml/hours
FLUID THERAPY

 CRYSTALLOID
 Based on their tonicity, crystalloids can be
classified as :
 isopotonic
 hypotonic
 Hypertonic

 COLLOID
 Always hypertonic
FLUID THERAPY

 ISOTONIC FLUID
 Isotonic fluids, such as normal saline
solution, have a concentration of dissolved
particles, or tonicity, equal to that of the
intracellular fluid.
 Osmotic pressure is therefore the same
inside and outside the cells, so they neither
shrink nor swell with fluid movement.
 Ex : NS, D5 1/4NS, RL, Plasmalyte
FLUID THERAPY

 HYPOTONIC FLUID
 Hypotonic fluids, such as half-normal saline
solution, have a tonicity less than that of
intracellular fluid, so osmotic pressure draws
water into the cells from the extracellular fluid.
 Severe electrolyte losses or inappropriate use
of I.V. fluids can make body fluids hypotonic.
 Ex. : D5W, ½ NS
FLUID THERAPY

 HYPERTONIC FLUID
 Hypertonic fluid has a tonicity greater than
that of intracellular fluid, so osmotic pressure
is unequal inside and outside the cells.
 Dehydration or rapid infusion of hypertonic
fluids, such as 3% saline or 50% dextrose,
draws water out of the cells into the more
highly concentrated extracellular fluid.
 Ex. : D5 ½ NS, D10 NS, D5 RL, NaCl 3%, NaCl
5%, NaHCO3 7,5%
FLUID THERAPY
 COLLOID
 The term colloid fluid refers to a sterile water
solution with added macromolecules that pass
through the capillary wall only with great difculty.

 Colloid fluids are used as plasma volume

expanders and have more long-lasting effect
than crystalloid fluids.

 Carry a risk of allergic reactions

FLUID THERAPY
 COLLOID
 Albumin
 Dextran
 Starch
 Gelatin
 Plasma
 Comparison Crystalloid vs Colloid

CHARACTER CRYSTALLOID COLLOID

MOLECULE WEIGHT SMALLER BIGGER

DISTRIBUTION FAST TO DISTRIBUTE LONGER TIME IN

TO ALL CIRCULATION
COMPARTEMENT
EFFECTS ON NONE DISTURBING
HEMOSTATIC HEMOSTATIC
FUNCTION
USE DEHYDRATION MASSIVE BLEEDING

CORRETION FOR 3X BLEEDING 1X BLEEDING

BLEEDING AMOUNT AMOUNT
INTRAVENOUS FLUID THERAPY

 PERIPHERAL LINE :
 Potential I.V. sites include the metacarpal,
cephalic, and basilic veins.
 Administered for short-term or intermittent
therapy through a vein
 Avoid using veins in the leg or foot  risk of
thrombophlebitis
 For neonatal and pediatric patients, other sites
include veins of the head, neck, and lower
extremities.
INTRAVENOUS FLUID THERAPY

 CENTRAL LINE :
 Administering solutions through a catheter placed
in a central vein, typically the subclavian or
internal jugular vein, less commonly the femoral
vein.
 Used for patients who have inadequate peripheral
veins, need access for blood sampling, require a
large volume of fluid, need a hypertonic solution
to be diluted by rapid blood flow in a larger vein,
or need a high-calorie nutritional supplement.
INTRAVENOUS FLUID THERAPY

 COMPLICATION :
 Infiltration, infection, phlebitis, and
thrombophlebitis are the most common
complications.
 Other complications include
extravasation, a severed catheter, an
allergic reaction, an air embolism, speed
shock, and fluid overload.